talked to T about the termination 'threat'

Just want to chime in to say how much I agree with this.

My T has *suggested* things I could try instead of using bad coping skills, or having bad boundaries with my mom, or whatever...but he has NEVER even kind of IMPLIED "you HAVE to do this thing"

A few months into therapy I was really struggling with sui thoughts. T talked to me on the phone for a long time, and at one point, he gently said "I don't want this to sound like a threat, because it's not, but if you attempt sui and end up in the hospital, I won't be able to work with you while you're in the hospital - that is their rule, not mine". And I asked him, when I got out of the hospital, could I still be your client? And he said, SO definitively, "Absolutely, without a doubt, NO question". I felt so so so so so much more safe knowing that no matter what stupid decision I made, T would still be there for me, and would still be willing to work with me.

My T's approach is like Sunny's T...he believes that I know what I need to heal. He takes that very seriously.

Interesting thread!

Yeah, if the therapist is telling the client what to do (instead of helping the client learn to work through information and come to a good judgement) are they going to follow the client around for the rest of their lives and continue to tell them what to do. Even if the client makes a poor judgement this is a time to learn and the client still needs that support from the T. The more that I think about therapy and healing, the more I think the best route is a simple developmental route. My role as a parent is to teach my children how to make good decisions. I certainly cannot follow them around and constantly make decisions for them.

ktgirl, this is a response to Dr. Muffin. Please do not take anything I say as a comment on your own T. Your own T responded very well to what you told her, and I think you are teaching her a lot by being so brave.

Study after study trying to prove the efficacy of one 'type of therapy' over another has yielded one simple result: The most important factor to successful therapy is the relationship the client has with the therapist. If the therapist does not feel capable of adapting to help the client, then I would advocate for that therapist taking a good hard look at why they refuse to change? Not put the onus onto the client.

I appreciate that you (Dr. Muffin) are trying to provide the therapists approach, but I respectfully call your approach into question.

*If* the therapist is feeling stuck in the therapy they need to examine any possible issues of counter-transference. It would be likely to find that the client is feeling stuck, and the therapist is acting as a mirror to for the client. Now, lets assume the client does not have healthy coping mechanisms when they feel stuck, they look to the therapist to provide healthy modeling. If the therapist starts to hint about termination, what sort of a message are they sending to their client? What lessons are they teaching them about how to respond when they feel stuck? What lesson are they sending to the client about trust? All of these questions, and more *should* be given due deliberation before a therapist even thinks about bringing it up with the client directly.

This attitude is, IMHO, harmful. It is harmful to the client, and it is harmful to the therapist. First of all, it reminds me way too much of what an abusive parent might say to a child who protests about X thing. "If you don't like living in this house by my rules, then leave."

Second it absolves the therapist of any real responsibility. It is the 'client's choice' afterall to be here, and if they don't think I'm working for them then they have the right to leave. It smacks of inflexibility and defensiveness.

The client absolutely should be empowered to make their own choices. When I have come into sessions and told my own T I felt stuck, his own response was 'What can I do to help you feel unstuck?' or 'Can you explain to me what stuck feels like?' I have always known that I can leave therapy at any time, because T repeatedly refocuses the session onto what I need, not what he needs. When he made a suggestion for a course of treatment, and I refused, he has never sat in judgement...he let me choose my own path.

It is sad to me to hear that therapists have these ideas about 'must treat X before Y'. On the one hand, the mark of an emotionally healthy person is the ability to adapt. On the other hand, this approach to therapy is decidedly rigid. Do you see the contradiction?

The client must commit to show up and do as much of the work as they are able, and the therapist has to be present and clear and focused on what the client needs. Maybe they need to really feel how frustrating being stuck feels? No part of threatening termination to a traumatized person is helpful.

I apologize for speaking so firmly about this, but I cannot stay silent. I have run into similar attitudes from mental health professionals before, and IMHO it is not an approach we should cultivate or condone.

Spotted Owl- Thank you for what you have written. I will, again, bring up my recent experince with the therapist who I left. She refused to be flexible, she refused to change her tough stance with me, she was rigid and defensive when confronted, and although she never said it to me, I know her attitude toward her patients is, "if my approach doesnt work for you, find another provider."

On the one hand, yes, if you dont work, I will find someone else. On the other hand, I left because she absolutely refused to take that hard look at why she refused to change her attitude for a patient she liked and needed her help. She never asked me what she could do differently to help me. Never. Because she knew she wasnt about to do anything differently. And what resulted was fueling the fire. I felt like a "bad" patient, too needy, too immature, I was re-experienced the invalidating environment I grew up with, I was almost always suicidal and SIing, and my ED was out of control. So, where was the healing with someone who wanted her way or the highway? I dont doubt that she wanted to work with me. HER WAY. And she wanted me to heal, HER WAY.

Her treatment approach was to tell me what to do....and question me in the following session...did I do this or that with food, if I didnt, why am I complaining? There was no discussion of how it feels to be stuck or what might be in the way of me stopping hurting myself with food. Do this, do that, if not, what could you have to discuss?

It is very possible that I was re-traumatized in therapy with her, I dont like to think of it that way b/c it just sounds too dramatic. But, the truth is, I am working on the horrible feelings I have left over from treatment with her. And the difficulty I have bringing things up with my new t for fear of getting a dt kind of reaction.

(((((TreeHouse))))
I wish I had your T!
When I was on the verge of going into the hospital in the spring.... my last T said that she didn't know if she would be able to see me afterwards, because she may not have room in her schedule.
And, sure enough, when I got out of treatment in July, she refused to see me and referred me to my current T.

Spotted Owl said:
Thank you, Spotted Owl.

I think your perspective is very well thought-out and makes a lot of sense. I like what you explained here:

It makes me think that maybe my T did make a big mistake by bringing up termination prematurely. When we spoke about the situation she asked me how she could have phrase it differently. I think any way which doesn't include the word "termination" would be good.
It certainly has affected our relationship. Although I am glad I brought it up with her I don't think I trust her as much. I'm not being honest with her anymore about my ED behaviors. And I don't feel guilty about lying to her, either. So, if I'm not being honest anymore, can anything more really be accomplished in this therapeutic relationship?

((((((BlueMoon)))))
wow - reading about your experience with dt was eye-opening for me, especially these parts:

This was how I felt with my last T, as well. And she always said that if I didn't try harder I would need a higher level of care, and she wouldn't be able to work with me anymore. Looking back, I felt threatened then too.

This is how I feel with my current T. She is mainly CBT, and we don't discuss how I feel about things, although she does help me on re-structure thoughts.

I'm sorry you had this experience, Blue Moon.

Ktgirl... it was good that you raised this concern with your T. I also liked your follow up question to her. I think you should also answer it for yourself... Is it really worthwhile for you to continue in therapy if you are not ready or willing to comit to working on your ED? If so, what issues would you work on? How would ultimately working on those issues affect the ED issue?

In my therapy I've chose to work on some secondary issues in hoping that I would become more comfortable with my T relationship and my life more stable. I think this approach has been working and I am now working more directly on my primary issue.

HOWEVER, my primary issue was not life-threatening so this was possible. With an ED that is life-threatening, working on other issues might be like....a firstaider splinting the leg of a man who isn't breathing.

You have to understand. I've been in therapy with this tdoc for almost 5 years. There IS a point at which we have gone over and over and over the same points again and again. I KNOW what I need to do, but I don't do it. It is self-destructive, static behavior. I know it. My tdoc knows it. I NEED a kick in the butt.

Oh, we definitely work on why I don't do what I need to do.

Oh, you misunderstand. He has definitely helped me "learn to work through information and come to good judgement". That's the point. I'm not using my good judgement. I'm choosing to ignore what I have learned. I need a good kick in the butt at that point. He isn't making decisions for me.

Talking about how you feel about things, you expressing your feelings is the therapy..............

Farmergirl, maybe you and your pdoc haven't uncovered WHY you are doing what you are doing? I get the feeling that this has occurred because he is too busy just trying to get you to change your behavior and skipping the part about understanding why you do what you do?????

No, not at all. We have worked extensively on understanding why I do what I do. I DO understand why I do what I do. I just choose to ignore the rational and fall back on the irrational. Bad habits are hard to break, and really, many of my thought processes have become bad habits. It takes time to reframe my thinking. I'm getting there.

Let me add some information about the type of things he tells me I must do. I have bipolar disorder. As such, there are things that I absolutely MUST do in order to stay stable. I HAVE to take my meds every day. I HAVE to be completely open and honest with my pdoc. I HAVE to keep a very regular sleep schedule. These are not options. Failing to do any of the above can land me in the hospital.

But . . . I have a habit of staying up too late either watching t.v. or reading, thus only getting about 5 or maybe 6 hours of sleep a night. This is a sure fire way to spark a manic episode and land me in the hospital. My tdoc tells me, yes, in fact, orders me to get to bed earlier. He's right. I know it. He would be negligent to say any different. Sure, we explore why I choose to stay up late, etc, etc., la, la, la. But the bottom line, is that I MUST change my sleeping habits . . . immediately. That calls on him to kick a little butt every now and then. I completely understand that and respect that. To do any less would be negligent on his part.

So why do you stay up late instead of choosing to take better care of yourself? Have you explored why you don't take better care of yourself?

Yup. I spend my days with 85 teenagers and my evenings with my own kids. They head to bed about 9ish. Late night is MY time. Unfortunately, it's very late and very bad for me and I'm very stubborn. Books are my addiction. I'm a voracious reader. Once I start, I get into the story and I just don't want to stop. I tell my self, one more little chapter won't hurt me too much. Sound familiar? My therapist in college wrote a letter of recommendation for me and used the word "tenaceous" to describe me. That's just a nice way to say stubborn.

Your need to have that time at night is more important than your need to keep your BP stable.

Absolutely not! When I become unstable, I end up in the hospital. Bipolar disorder is a very serious mental disorder. Hmm. Read a book . . . or . . . get depressed or manic, become psychotic, become suicidal, end up in the hospital for two or three weeks. As my therapist says, that's really a no-brainer. That's why he's so blunt with me. It's the best way to get through my thick skull.

You must not really believe that if you aren't doing it............ (if you are choosing staying up over taking care of your BP).

Oh, I absolutely believe it. I just make poor choices from time to time. One of the problems with bipolar disorder is that when you feel good, you feel really good. And sometimes you even talk yourself into believing you don't need the meds anymore or you won't be hurt by staying up late, etc. It is very typical bipolar behavior. That's why so many people with bipolar disorder struggle with medication compliance. It's a chemical thing and a psychological thing. Sometimes it is hard to keep a handle on both aspects at one time. The nature of this disease is cyclical, and unfortunately, I am one of those patients who rapid cycles despite medication compliance. Very chemically treatment resistant. So, despite intellictually knowing and believing what I need to do, my body betrays me from time to time. When that happens, my thinking gets screwy and it takes a firm hand to get me to do what I need to do for myself. No amount of delving into the deeper meaning of what I am doing will help because until my body chemically stabilizes, my mind won't do it on its own. Bipolar disorder can be a really vicious cycle.

I'm dealing with this with my son right now. He was diagnosed bipolar last summer and there really was no talking with him at the time. Therapy is useless when your in the midst of an episode. Your thinking is pretty much psychotic, definitely not rational, and no amount of exploring the nature of what you are doing really helps. You have to be chemically stabilized and THEN you can think again. In retrospect, you can see how messed up your thinking was, but in the storm of the episode you think you are making perfect sense and the rest of the world is insane.

I'll have to take your word for it that you can't reason with yourself with BP since I have no personal experience with BP and I don't go to the BP board here. I don't ever accept "there is no answer" for anything. I have never come upon anything where there was no answer.

You sound very confident about your treatment.......

But there is an answer: a firm support system, medical intervention. It's just not the kind of answer you are talking about. When a person with bipolar disorder slides into an episode, the first things we need to do is contact our psychiatrist, a medical doctor. When my therapist sees me slipping, that's the first thing he expects me to do. He's even had me call from his office. He says, "Call Dr. M first; call me next." He knows there is only so much he can do for me as a therapist until I get the episode under control. But you see, that IS the answer in those circumstances. We have an intervention plan that we follow. Many of our sessions in therapy have been on the topic of, "Okay, we dodged that bullet. Now. What are the signs that you are going into an episode? What will you do next time you go into an episode so it doesn't get as dangerous?" Very step by step, concrete learning.

And yes, I am very confident in my therapy. I've dealt with my childhood issues and have pretty much put them on a high shelf. I don't need to look at them anymore. They aren't helpful to me as an adult. That's over now. I can live with the confidence that I'm safe from that harm.

I've gained so much autonomy through learning my boundaries, improving my communication with my husband and children, reframing my beliefs about myself. Those are typical therapy things. I just happen to have this complicating factor of bipolar disorder. It has to be dealt with on a different level.

My therapist works with both aspects of my therapy. Sometimes together. Sometimes separately. It depends on where I'm at. He meets me where I need him.

Thanks for the info Farmergirl. I will definitely file this away in my head for further pondering. I actually believe that BiPolar develops with those individuals who are prone to it because of their environment while growing up. My "primitive theory" is that the environment was such that it caused this dysregulation in emotions. Continuing further with this theory is that this dysregulation can come under control with self understanding and a good therapist who feels that it can be worked through. We are just at the beginning of understanding psychology I think. I have an MSW and spent years listening to mental health professionals not really understanding what is really going on with their clients (but there are good therapists out there!). I then come to these internet boards and learn from the clients perspective and it blows me away how much disconnect there is between the clinicians and the clients. The info is there if anyone just wants to listen and work at understanding. I guess I need to spend some time on the BP board trying to learn and understand.......

Yeah, I've enjoyed our conversation. There's much evidence that bipolar disorder is genetically linked, and it is generally very responsive to medical intervention (i.e. lithium, anti-convulsants, and anti-psychotics). Anti-depressants can send bipolar directly into mania, as well as some cold medicines, steroid treatment like for breathing problems. I have to watch myself when I use my asthma medications for instance.

The social workers at the hospital say that the genetic link can be as far back as 7 generations, thus the reason not all of us know who we may have inherited it from. I suspect my grandmother, but in those days, they didn't treat such things. My husband suspects his mother, but she's too stubborn to see a psychiatrist (but boy does she need to).

Mental illnesses are medical disorders as well as psychological disorders. While a few people with bipolar disorder can function well without medications, most need them. Many people with bipolar disorder are so disabled by the disease that they are unable to work. I'm very fortunate that I have been able to maintain my career.