Suggestions for Mental Health Professionals dealing Challenging Cases

I don't see anyone where stating your first point, heretoday. On the other hand, I do see the viewpoint that all therapists have no clue what they are doing and if it works, it was just luck -- that therapists are basically "muddling their way through". I objected to that based on seeing repeated successful therapy in the hands of skilled therapists not only for myself but for quite a few people of my acquaintance.

Certainly there is a need for therapists to have better training to handle complicated cases. I see no one here saying any differently. I do see many of us saying we would rather continue with the ability to make our own choices about our therapy instead of having some test place us with someone that we wouldn't choose. Perhaps the option for that assessment to those who desire it makes sense, but clients also must have the option to say no to such assessments and have the power to stay with the therapist of their choice.

I don't think this is a lame thread, nor do I think opinions are as polarized as the two options present. In my case, I definitely assert that my generalist does not have the skills to help me. I have a complicated diagnosis, DID plus treatment resistant depression plus mixed personality disorder. T1 really has no clue how to help with that. He does well with family therapy, couples, grief, addictions. He does refer out cases that he believes are beyond his capability. In my case, we started couples counseling and that went fine. Probably should have stopped there. But I didn't and that is a long story.

What I think (and I think I said this above) is that generalists need to be willing to say that they are in over their depth, refer a client, and. continue to see the client if the client so desires. I think the belief that a client can't work with more than one t without muddying the waters is just wrong. T3 has extensive training and experience using a treatment modality that has been acknowledged to work for dissociation. The work that I do with her is what is really helping me. After 9 years, the treatment resistant depression is lifting, I actually believe that I will get better. I rarely lose time anymore. I can take some risks in relationships. Definitely due to work with T3.

Meanwhile, T1 continues to see me, even though I continue to freak out over abandonment. He is patient and consistent. He "muddles through". But I believe that him terminating with me would have been. Well, lets just say worthy of a trigger warning.

T1 has even referred a couple of clients to T3, now that she sees some value in a client seeing both. I must say that it took quite a bit of convincing to get her to go along with it, but she was willing to give it a try and now thinks that it is working for me.

Obviously therapy doesn't work for everyone. I read posts here by people who have been hurt, badly. I do think there could be a way of rating ts, I think that all ts should welcome information about how they have/have not helped. And because people are people, there needs to be some oversight. I wish that there was a way for people that have been hurt by incompetence or meanness or bad judgement to get some sort of resolution. But I am not sure what that would entail. Money would not recompense for the kind of suffering that I read about here. I wonder what would?

Thanks for your suggestions and for more detail about how the gneralist-specialist arrangement works for you. Seems like something which could work for others, too.

But what if the therapist's therapists were mentally unhealthy? Or what if the relationships were troubled or ended badly? What if a therapist's therapy did more harm than good and left them less able to see clearly?

I am one of those who believes therapists just stab and hope. I don't think they do anything really.
I see it more as even a blind pig can find an acorn every once in a while.

Did you take my statement as a proposal or are you asking me to clarify how it actually works in psychoanalytic circles? I'm assuming the latter.

As far as I know the candidates (for psychoanalytic training) are first selected through discussion where their suitability for the profession is evaluated by a committee of analysts. Then they start their own analysis and after one or two years their progress is evaluated - have they learned and gained enough insight from their own analysis. The training analysis is conducted by dedicated training analysts who have assumably proven themselves already. If the evaluation goes well then they can start with theoretical studies and later also supervised case work, while still continuing their analysis. It is possible that some people need further work with themselves before they can continue with other training parts, or that someone never gets there.

I don't think this process is perfect but it certainly filters out as many unsuitable people as possible. How to implement this model to all therapists I have no idea and I did not actually propose it. My point was just that when choosing a therapist it would be perhaps better to choose someone who has had enough therapy himself.

This is an interesting thread. From the opinions expressed here, I most identify with lolagrace's. I've also found an eclectic approach most compatible with me and thus the most desirable and helpful. Psychoanalysis in a purer form was interesting for me but had serious limitations and many areas I personally disagree with and find outdated. My own view on therapy is that it can be anything really... in a large part what the client infuses it with. If we are in a phase and state of mind that we want to be helped by others and are receptive to their input, there will be plenty of apparent influences from a therapist, good and bad, depending on context. Or from our friends. I think "success" with therapy can be quite random and hit-and-miss and I definitely don't see Ts as some kinds of seers or people with magical abilities to penetrate the human mind. In my experience, most Ts usually have one or a few favorite beliefs and if I can choose, I prefer those with at least a few, I like flexibility. So in this sense I guess a generalist works best for me... but I don't have a background with severe traumas, abandonment, or personality disorders. Yet, both of my therapists (an analyst and an eclectic T), as well as most of my close friends, described me as highly complex and complicated repeatedly. I actually felt that it is exactly because of the complexity that I mix better with someone who has diverse knowledge and a holistic view rather than focusing on only one or a few elements of the complex, with an idea that there is some sort of "master drive" behind my issues and eccentricities. (This is why I got inpatient with psychoanalysis, putting so much emphasis on the past and on the role of parents... it gets old for me quickly as I consider myself an adult living and interested in the present and future primarily.) I've definitely had issues that stand out in terms of severity and the extent of dysfunction they cause in my life but I did not have much success trying to treat those as isolated factors.

I also think that pretty much everyone is complex, complicated and a unique case. What's probably more important is how we handle our complexities and what sorts of problems they cause in our lives. Many people carry a significant amount of remarkable baggage and yet are able to function well and manage to find a niche in life that allows for the integration of the whole person with quirks and all. Also, I very much like a pragmatic therapy approach that focuses not only on the problem but also on possible solutions that can be turned into practical action, although I believe that implementing any solution is ultimately up to the client and no one can offer change externally.

I think that both generalist and specialist approaches can be helpful, or a combination of the two as some pointed out here. Depends on the case and the client's own mentality what they respond to well and find useful.

Thanks for sharing your insight with us. I have been severely hurt by a previous T and have been begging him to be forthright with me to no avail. I cannot, for the life of me, understand his unwillingness to be honest and open with me. He believes in keeping secrets, not only with clients but also in his personal life. I'm trying to figure out what my T's problems are. He may have survived his own life struggles by lying, and that has become ingrained in him. I cannot go on until I get resolution with him.

Back to your question. The only resolution I am looking for is the truth but my T cannot face the truth. Where do we go now? I need the truth that he is bent on hiding from me. But WHY?? Why not the truth?? This is MY LIFE AND I HAVE THE RIGHT TO KNOW. I was a paying client here and now my life has been permanently screwed by a T who did not know what he was doing. HELP!!

Kecanoe

Im not sure if that many of us could afford 3 therapists.

I can barely afford 1 as I have to pay cash. If i could find one who took insurance, I could afford 2.

Nice you have something that works though.

I agree about seeing more than one of them. I see two regularly and consult with others from time to time.
For me, one was a disaster - hiring two of them made it less of a disaster.

There's a few useful things that can be taken from the psychoanalytic model, as I mentioned too. This is one of them.

One possible advantage of seeing more than one therapist (in addition to different expertise), in my view, could be trying to condition the self for not expecting everything from one source. Compartmentalize the support (or whatever is sought) as a kind of puzzle. Maybe alternate weeks with different therapists. A bit like having different teachers for different subjects at school or different friends for a variety of activities. I would never accept a T who suggested that whatever approach I want to try is wrong... If it's not something they want to deal with, fine, then look for others who are compatible.

Also, doing more that just therapy for mental health and balance is probably never a bad idea. There are many free or cheap things to explore. Peer support (company of people who share my problems) has been instrumental for me for special and outstanding issues - far more helpful than any therapist. I think that mental help professionals often try to monopolize the field when often people who actually dealt with and successfully resolved a problem can be far more understanding and also practically more helpful with tips etc.

That's an important difference between us, I think, and I really appreciate the way you offer your comments within your own context, which you also make clear.

That's hard for me, and perhaps others with what Skies originally called "challenging cases" -- challenging cases to the therapists was the original meaning, I think -- at least that's how I interpreted it.

I also liked your description, I'm not sure where it is now, about your experience with your T who used the model of modern psychoanalysis and how you ultimately decided there was no place for his "way of being", if that's a fair description, in your life.

I liked that because it helped frame some difficulties that I think I have with being in the world and the way my "way of being" impacts others. Lots of times feel that I'm caught in something I can't escape from. A logical answer would be the "narcissistic defense" you mentioned earlier. There may be other self-absorbed, previously traumatized people for whom this is true, too.

How can I get out of this whatever-it-is? I'm pretty sure that I need an accepting social environment, in addition to therapy, rather than the one in childhood in which I developed what my last T called an "anxious-ambivalent" attachment. Yes, therapy to get at the trauma and other "pathology" but then, also, a connection, a way to be a part of the world at large.

A supportive, generalist therapist might help provide this sense of bridge between me and the world. Some sort of group, and maybe social awareness education, might help, too. DBT did not help me, probably because I don't "have" BPD, but I understand it's helped lots of other people.

As I've also said before, PC has helped a lot, a safe place where I can try out "being myself" and it's not devastating when I miss a mark or come off as someone whose "way of being" is not one that some others may want in their life, but that doesn't mean I'm rejected as a person, either. That helps me begin to understand my self in a larger context, too. Which eventually, in addition to awareness gained in therapy, may help my "way of being" in the world to be more comfortable for me, and people around me.

Or not. I'll see, I guess.

This is available for free in my state but didn't help me a lot because it was primarily designed for people who use state programs and are frequently on disability, which I am not, or have what is often called "severe and persistent" mental illness, which I don't qualify as either.

Nevertheless, the state developed the programs to help save money and help keep people out of state hospitals. So that's maybe an approach that could be taken with insurance companies, too.

I think this is the think tank for therapies for complex clients. Anyone who feels they are a complex client could email them for a referral. I'd bet they have contacts in other cities.

The Personality Studies Institute Model of Personality and Psychotherapy

Although personally, I think all that is needed is for a therapist to help integrate, which is the root of Complex-PTSD. But to do that, they have to help a client work through anger and rage while remaining strong enough to contain in. Which would require them to have down their own therapy.

People with trauma mostly all have splits. People talk about this a lot-about not being able to be angry, express anger. Or expressing it at themselves (self-destructive behavior and feelings). I'm not sure that enough therapists have training with object relations, which is designed to integrate. Perhaps their are other ways, too.

My questions were mostly rhetorical, and meant to challenge the idea that a therapist's skill or sanity or effectiveness is in proportion to the amount of therapy they've had. I think it could well be the opposite. I do think all therapists should have done their own therapy, just so they have tried out the product before selling it, but I don't think it's a reliable indicator of anything.

I have amazing insurance. And widely accepted. I am very fortunate.

Well, I do. I personally wouldn't see anyone who hasn't gone through their own long-term therapy.

As much as I've read other's experiences (and I've read a lot) then the most common problem with therapists who haven't had their own therapy is that they tend to get entangled with their patients. They don't understand what's theirs and what's coming from the patient. Then they start taking things personally and then the possibility to do any therapy is already gone. T's own long-term therapy is precisely such a thing that enables one to get to know themselves, so that later in their work with patients (especially difficult patients) they are able to recognise what is projected by the patient and what comes from the therapist and then are able to put their own stuff aside and work with the stuff that comes from the patient, without taking it personally.

So, although someone's own therapy doesn't obviously guarantee a great outcome with a random patient then it most certainly minimises the chances for many problems that just prevent doing any therapy at all.

Sometimes I see that when one of those people have done their own long term therapy - they think they are immune from such entanglements because they believe they accurately can assess what is theirs - I have not found their assessment to be as accurate as they believe.

Yes, the entanglements.

I think it’s fair to say that’s something that happened with my last T and me, even though she had done her own therapy, did consultations, “all the right things”, etc.

Somehow if there were a way to work through that – but with me paying out of pocket that seemed an exploitation for an uncertain benefit to me. The psycholanalysis model is different, the analyst stays out of things as much as possible. But I need not only to understand my own psyche but to learn or understand how to be a part of the world.

A “peer group” situation could help solve some of that, I think, at least for me – but so far I have not found anybody among my support group peers who would be interested. Partly, maybe, because I don’t want to “push” the idea that there is something “wrong” with any of us, even though we know we all have mental health issues, because at this point we have a friendship group, not just a support group.

I’ve also considered trying to start something on Meetup.com. People could bring in their own stuff from the literature to discuss, I’m certainly willing to look at traits from personality disorders in the DSM that I think may apply to me and/or other people could call me on – but without anybody expecting that I would or could change any of them overnight. I could accept others with their stuff, can they accept me with mine? And with that base of acceptance, that’s something I feel I could “branch out” from to try something different.

Would that kind of thing appeal to anybody here? Not that I’m asking anybody here to “join” because we all live so far away. And if it appeals to you in part, do you have any suggestions or criticisms of the idea?

I was just going to suggest the same thing! I used Meetup.com this way and while not all experiences were good/helpful, I did find some people I could really relate to and who have similar interests (not just issues), this way. My main issue is dealing with addiction/obsessions. There are plenty of free, peer support groups for this with long tradition, history, and a variety of programs. I tried those as well but at some point I was just looking for something more relaxed and friendly, with people similar to me, who favor a similar lifestyle and have compatible interests. Make some new local friends for activities and interesting discussions, not always strictly around our issues and in an unstructured way. I've made a couple quite valuable connections using this method.

Yep, it could happen. I don't think there is anything that would guarantee that all the people who really should stay out of the field would stay out of the field. But for those who are actually suitable for the profession more personal therapy is definitely better than less or none at all.

I can understand that. After 3.5 years of intensive 1-to-1 psychoanalysis I have started to think that I might become ready soon to start learning how to be part of the world. When previously the thought about some group work seemed completely outrageous to me, something I would have avoided at all cost, then I've found myself recently thinking that it could be quite interesting and useful for me. But it has taken me 3.5 years 4xweek with my analyst for those thoughts to emerge.

I do think those people should endure therapy before going out and inflicting it on others. I just don't think it does them any particular good in terms of dealing with client except perhaps to understand how horrible enduring it is.

Avoiding the entanglements is on the surface. But avoiding enmeshment, which I see as the higher benefit, allows us to be an individual person with needs, thoughts of our own; to become our true selves without others' needs overtaking or influencing us or imprisoning us.

Trauma can cause us to become what our parents/abusers needed, introject their own hate and shame, or be objectified by being used for their gratification. Then we grow up treating ourselves like we were treated. Unworthy of being an autonomous individual with wants, needs of our own. That can leave us growing up to be apathetic, lacking in motivation because we repressed all of those impulses, almost permanently as a result of being rejected, punished, or shame for having those needs. That energy is locked inside; frozen from an early age. We end up being imprisoned within ourselves.

Some of us turn into chameleons. Others people pleasers or shutting people out entirely to avoid the stress of relationships because they are stressful and immensely draining when you can't just 'be'. Some call this being an empath or highly-sensitive person (HSP).

For those who were not abused, I think a parenting always jumping to comfort a child never allows the child to develop the ability to deal with emotional pain. I see many good parents trying to solve their children's problems rather than guide them through to solve them on their own (age appropriate of course). The need to stop the pain usually comes from the parents' own pain/guilt/shame rather than what's best for the child. And the overly intrusive parents...that can really stunt someone's emotional maturity, yet they might be seen as caring and not abusive. Those are usually ones living through their children, which is objectifying the child.

That's how a therapist's own therapy contributes the most, I think. But to your point, here today, it has to be depth therapy. Sorry for the tangent.

Of course, it didn't prevent my therapist from getting enmeshed with me recently. But it does help a lot in comparison with other therapists I've been to who were seriously lacking emotional health and stability. If you think about it, it helps with the entanglement, but the therapist's needs are still there. That's what I found to still get in the way despite their own lengthy therapies. I suspect my therapist has a need for me to get better on his terms rather than mine.

Love your idea about Meet Up, here today. The only concern is structuring a group in a way to keep it safe. I'd like to join a therapy support group myself, but am afraid to put myself out there in the public to start such a group. Maybe a trauma survivor's group? That sounds nice.