Tips for working with patient

[MidWestLass]

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Hello!

I have a new therapy patient who does not have a lot of insight and seems to have a lot of difficulty connecting to any of their experiences in any meaningful way. I’ve tried asking open-ended questions to get them talking, but they’ve asked that I ask more targeted specific questions. It’s not the usual “patient just won’t open up” presentation where they simply refuse to answer questions or give one word answers. It’s like they are unable to answer questions unless I am very, very specific. Do you have tips for working with someone like this? I’ve thought about working with them on a life timeline as well as helping them to expand their emotional language vocabulary. Would love other ideas and/or reading recommendations. Thanks!

 

[bcliff]

Why are they seeking services?

 

[MidWestLass]

They have PDD, social anxiety, and frequent(ish) panic attacks.

 

[bcliff]

What are your treatment goals? Behaviorally-based interventions (e.g., in-vivo exposure, behavioral activation) can be implemented with relatively few open-ended questions. I'm assuming PDD = dysthymia, not pervasive developmental disorder -- Is that correct? Obviously defer to your supervisor if you are a trainee, receiving supervision for this case, etc.

 

[ClinicalABA]

Hello!

I have a new therapy patient who does not have a lot of insight and seems to have a lot of difficulty connecting to any of their experiences in any meaningful way. I’ve tried asking open-ended questions to get them talking, but they’ve asked that I ask more targeted specific questions. It’s not the usual “patient just won’t open up” presentation where they simply refuse to answer questions or give one word answers. It’s like they are unable to answer questions unless I am very, very specific. Do you have tips for working with someone like this? I’ve thought about working with them on a life timeline as well as helping them to expand their emotional language vocabulary. Would love other ideas and/or reading recommendations. Thanks!

Are you a student or intern? If so, please speak to a supervisor regarding this issue. If the "PDD" refers to a Pervasive Developmental Disorder, is there any potential to refer out to a therapist with experience in working with individuals with such a diagnosis?

 

[MidWestLass]

Thanks! I am referring to dysthymia. There is no plan to refer out to another provider since I was assigned this person as a long-term therapy case. My program assigns us a few cases with the expectation that we would work with them for at least 6 months. I think they selected this patient knowing that it progress would take time. The goal of these long-term cases is to provide us with a more intensive therapeutic experience to explore psychotherapy more deeply than the usual manualized treatments.

I do have a supervisor, but I do typically like to go into supervision with some ideas before they inevitably ask me if I have any ideas. I understand if this is not enough information to go off of, and will absolutely discuss this in supervision.

 

[123EW]

It's okay to feel stuck on a patient. If your supervisor doesn't understand that, they don't understand supervision.

 

[Therapist4Chnge]

Your supervisor would be best positioned to provide specific feedback. I would put out there that behavioral interventions to address anxiety can be helpful bc they don’t require much if any insight to do. Setting up a hierarchy for in vivo exposures, teaching specific coping skills, and having them do complete items on the hierarchy can provide some concrete experiences from which to work. Hopefully that helps.

 

[psych.meout]

Not every therapy works equally well for every person with same constellation of Dx. Some people are just more concrete than others, or maybe they just prefer their therapist to take charge of their sessions instead of leading therapy themselves. This is where matching the evidence-based therapy to the Dx and the person is important.

As Therapist4Chnge pointed out, there are many behavioral interventions for anxiety that seem like they would match well with this patient. Similarly, behavioral activation could be helpful to address their depression despite their difficulties discussing their problems at length and providing you with feelings or cognitions about their problems.

You could also address this issue directly with the patient. If you've built up enough rapport, you can present the frustration and uneasiness you have from them being less forthcoming outside of direct questions. This could potentially reorient them to therapy, but it also might not work if this is just what they are like across contexts.

Thanks! I am referring to dysthymia. There is no plan to refer out to another provider since I was assigned this person as a long-term therapy case. My program assigns us a few cases with the expectation that we would work with them for at least 6 months. I think they selected this patient knowing that it progress would take time. The goal of these long-term cases is to provide us with a more intensive therapeutic experience to explore psychotherapy more deeply than the usual manualized treatments.

I do have a supervisor, but I do typically like to go into supervision with some ideas before they inevitably ask me if I have any ideas. I understand if this is not enough information to go off of, and will absolutely discuss this in supervision.

I get that supervision can be uncomfortable, intense, or embarrassing at times, especially depending on the supervisor, but the point of supervision is that you're willing express your own thoughts and feelings about the case, even if you're at a loss for what to do or have unpleasant feelings about your experiences. What's really important is that you're receptive to feedback and are able to learn from every experience, even if your supervisor isn't handling you with kid gloves.

 

[CatLover&PsychEnthusiast]

Not a comment to direct tx, but for understanding the presentation, could it be alexithymia? I might also consider their health literacy/mental health literacy level. But perhaps that’s something you’ve already considered.


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[Murielle]

Have you done any testing, like a personality inventory? That could give you more insight into the interventions that may work for this patient!