Suggestions for Mental Health Professionals dealing Challenging Cases

I agree with the danger that you mention.

Again, it's great that you have a therapy situation that worked for you. I did not. I've been in and out of therapy for over 50 years, almost continuously since my late husband died 18 years ago. It would be easy to look at me and find reasons why that's my "fault" but to me it's the "faults" that I went into therapy with and wanted help with that I haven't found or received.

Perhaps the complex case assessment could be a tool that the client could be offered and decide for themselves whether they want it or not and what to do with it after they get it. It's certainly something that I would have wanted had I known it existed 25 years ago or more.

But . . . who's to look out for that? And are people with complex issues in a position to effectively determine that about the therapist for ourselves? I understand that we are legally, but because of the issues we come into therapy with, are we realistically "able" to do that? I think not, based on my own experience and that of others I have read about on PC. So we end up wasting years on ineffective therapy or worse.

How many of us are there like this? Again, because nobody has done the studies, nobody knows.

It doesnt put people in boxes. It matches clients with the best therapist for their issues.

A psychodynamic case formulation comes out of that, assessing strengths and what can be done to help. A treatment plan may be done. This guides treatment, not a diagnosis.

A client gets matched with a therapist based on personality, interest, expertise, skill. As opposed to just talking to someone and filling out the stupid papers and being asked about symptoms and a brief history that doesnt even point to potential issues. Symptoms are an incomplete assessment do not lead to that much insight into a clients' issues. Intakes like that are the reason that a clients issues arent found until months down the road. And not matching clients up to the right person, which is the status quo, helps setup the therapy for failure.

Thats really odd. Ive never been to a GP in the UK, but here, i dont think GPs are qualified to make MH diagnosis with accuracy. Sure, the can check off symptoms from a checklist, but that only is but a small glimpse into the issues of a client. Psychiatrists often do the same, ad they aften treat to symptoms rather than diagnosis because the medication limitations.

That works if you have access to a clinic or centre with different therapists with different specialists but they're fairly limited outside of major cities in the U.K. I had a few bad turns of the dice before I found the right person and experienced the worst of assessment, formulation and treatment - I was diagnosed with GAD when I actually had PTSD, the "recommended" treatments for both conditions clash and so I got steadily worse while being told I was getting better.

I also know of therapists who see PTSD/depression whsyever and run through the exact same treatment protocol for everyone with that condition regardless of what they individually need.

It's not an easy thing to find the right therapist and I don't know what the answer is, I do know what worked for me which is as valid a basis for thinking about therapy as your poor experience is.

For me that's a huge part of the problem though, if you follow a medical model for mental illness you're only ever going to treat the symptoms - medication, the 6-12 session CBT etc are designed to keep people functioning but aren't designed to get to the root of the problem. GPs do diagnose depression, anxiety etc and yes against the diagnostic criteria of the DSM5 but ultimately that's what all diagnosis is.

I wonder if we're actually talking about something different, i.e. the difference between I have depression/PTSD etc and I have depression caused by X and I want to deal with X rather than the symptoms of depression?

These are actually independent practitioners doing these assessments. Psychoanalysts are generally more community based and have organizations/institues with memberships. They have information available to know who works good with cliemts who have xyz needs.

The way they do assessments prevents the problems you mention here This type of therapy is very individualized, though my own therapist has gone off track at times.

As i mentioned earlier, typical assessmemts are mostly symptom based, which is only a tiny window into into a person's psyche.

Sorry about your experience. Ive been misassessed by many therapists and psychiatristd over the years and wasted a lot of money on band aid treatments. I didnt even know what my issues were until i saw an analyst. Except for PTSD amd GAD which is a small part of my issues. I had complex ptsd but was only treated with meds and superficial therapies.

Haha i dont know what we are talking about anymore.

Psychodynamic therapy treats tbe whole person, not the symptoms, and its individualized. It takes forever though. At the same time, people who need more intensive treatment will be seeing psychiatrists and therapists for decades anyway.

But its also to help clients live to our potential rather than the status quo which is to keep treating symptoms with band aids.

I dont agree with the cookie cutter treatments either. GAD and depression are often symptoms of larger issues to begin with.

Yes to the bottom paragraph, the approach is to treat the root of symptoms rather than symptoms themselves.

My therapist is person centred so also treats the whole person but is much less focussed on diagnosis and deals with transference in a completely different way in that she sees all feelings as belonging in the relationship and works through them in that context. I think for both of us it seems like long term relationship based therapy has been the answer - whichever modality is I think a matter of personal preference.

The medical model is a how people are helped issue. We know that the body is a whole system, there is interaction between medicines, different people's bodies respond differently to different drugs for the same symptom, different people have different blood types so you have to match the blood types for transfusions, etc. There is enough natural science knowledge so that works pretty well -- some exceptions, people get upset when they're on the receiving end of an exception, etc.

What is available in medicine to get to the root of a problem are things like MRI's, blood tests, etc. They don't give a precise answer sometimes but something more than just treating symptoms on the surface.

That's how I see the assessment that Skies has suggested -- an early equivalent of an MRI. May have a lot of bugs and inadequacies yet, but it sounds like a start.

What people do with the results would then be a how-to-use it issue for clinicians and maybe clients, with lots of education and informed consent materials, respecting the client's responsibility to make decisions based on the best information which is available.

Currently, for instance, I think if a therapist believes that a client has an "attachment" issue, then the risks of getting into an attached relationship with a therapist need to be discussed up front, as well as some specifics about some possible benefits. How to convey information about those risks and possible benefits? An unanswered question but I think there are people who do this kind of thing for business. "Human factors" psychologists may be some of them.

Sure, i agree with treating the root of the problem via whatever means.

Its like we would use functional and integrative medicine instead of prescribing pills for symptoms like us done in the US. In the medical world, they often dont look for the root cause and are very bad at diagnosing-determining the nature of the problem and cause. They dont know what the problem is but just start treating it.

So for therapy world, these assessments would figure out the nature of the problem so that appropriate treatment is given.

Ive had issues with western medicine where i was made worse off because no one looked for the problem.

So its not just therapy, its healthcare.

It likely wont change till hell freezes over though.

I just saw your post HereToday, we toched on similar things. Ha

I do think it is a good idea for specific clients to have specialists. For example, people with trauma, or at least complex trauma, should see a trauma therapist and someone with an eating disorder should see an eating disorder therapist. I don't know about "challenging" clients, since that definition varies for different therapists. But for very specific issues like trauma and ED's, it can be really useful. These people tend to have the generalist like you say along with this "specialist". The thing to be aware of is that very few therapists become specialists through training, but rather through experience. I know it's possible to have varying certifications, but its more common for someone to say they specialize in certain disorders because they've worked with people who have those disorder. In my opinion, a real specialist sees only, or mostly, clients in their area of expertise.

There is a model of clients having case workers and a "team" of therapeutic providers in my state. Only people who receive state funded insurance qualify, which is unfortunate because clients respond really well to it overall. Most people like having a "team" that communicates with each other (and with the client). It's much more commonly used with children, but it is available for adults too.

You’re coming from a position as a mental health professional, am I correct? I’ve seen some of your posts before and it seems to me I remember you saying that.

Have you seen enough posts from those of us who have been hurt in therapy that you understand a little about where we are coming from? And, if so, what are you prepared to do, if anything, within your profession to try to help the situation? Simply describing how the system is, from your perspective, I don’t find particularly helpful – it feels to me more like a defense of your industry and the status quo.

Earlier in this thread I suggested that perhaps NAMI could help, from the consumer standpoint. But I – and others whom I have known and identify with – do not have “severe and persistent” mental illness. So NAMI has had little to offer me so far. I am economically independent and so don’t get into the state mental health system. (There have definitely been times in my life where I think this has been a disadvantage.) My mental illness might be described as “moderate and chronic.” I can’t speak for others, of course, but I believe that I and others like me don’t have much “voice”. We don’t have an advocate because we are economically able to take care of ourselves and not legally incompetent. Yet I know that I have had a hard time knowing what I want or need and speaking up for it and I suspect that others like me may be in a similar situation.

I life a “half-life”. Some relationship with my adult children which I (try to) maintain because they are important to me, but it’s not easy. I’m depressed, don’t want to be here, but “that’s my fault” and it would “hurt others”, if I were to voluntarily exit my life. I don’t plan on doing that and on a personal level there still may be some hope, though it’s scant and I feel a bit like a fool for having it.

I have insurance for my regular medical care that I like a lot. The mental health benefits aren’t very good and so I paid out of pocket for a trauma specialist for 6 years. That therapy ended last summer. I don’t think she was trained or personally competent to handle or help with what might be called my “ego and identity” deficiencies. I have reason to believe that she came to the same conclusion, too. But she had a Ph.D. and an internship and post-doc in trauma and dissociation so I think both of us going in believed that she could handle what came up.

What more does your profession expect a client, by herself as a consumer, to do to try to get help? I’ve been in IOP and PHP programs, too – band-aids, helped a little with present-situation anxiety but NOT helpful to my overall psychological situation.

Again, thanks for the information, but I hope that you can understand my frustration with what seems to be the "just don't get it" aspect of what you had to say.

Therapy should focus on the individual and their goals. I think psychotherapy focuses way too much on 'trauma' and finding its source. In some situations this is very inappropriate and can cause permanent psychological harm. Digging for evidence and even suggesting incidents (the fabrication of false memories) in my opinion is appalling and unethical. For others it is appropriate to work through trauma. Since we are all individuals with unique histories I don't think it is right to lump all psychotherapy clients in one group.

Not all clients end up in therapy for trauma related to early childhood and family dysfunction. One can end up in therapy for a multitude of reasons. I don't have a history of abuse, PTSD, personality disorder, addictions etc. I struggled because of undiagnosed ASD.

I'm not sure what a challenging case is. Is it someone who failed at therapy over and over again? What does failure mean? Is it the psychotherapist's interpretation or the client's?

I'm sorry to come across as insensitive. I was honestly just replying to another post in the thread that referred to the use of case managers in for such clients. I wasn't intending to give an opinion beyond that it's a model that seems to work for some kids and it's too bad it's not available through private insurance or for as many adults. Whether or not you are "getting" anything or not wasn't even on my radar, I was just sharing information. Yes, I am in the field but I generally use this forum as a consumer of mental health services, not a provider. I can refrain from posting if it's not appropriate.

On the other side, I like the fact that the only people involved in my treatment is my T and me. I got to choose him, and I did so because of his experience. I know my trauma history can be challenging for some people, and I wanted someone who could handle it without blinking. The idea of having someone else dictate to me who I should see, and how I should be treated, kinda feels like it might be re-traumatizing. That's my thoughts.

I think a basic problem with trying to screen clients with the goal of matching their problems to a therapist's "expertise" is that talk therapy is not like medicine, and there aren't established procedures or interventions that can repair emotional distress or trauma the way surgical procedures can fix a faulty joint or a change in diet can resolve a digestive problem with reasonable consistency.

If a therapist has studied trauma extensively and then presumes to translate that intellectual understanding into a replicable clinical method that centers on engineered relationships with real live humans each of whom is totally unique, I'd say there is some magical thinking involved.

I think the fallacy is that someone can be trained to deal with the psychological difficulties of other people. Would be more honest if they just told each client up front that they do not know what they're doing, and that they just muddle through with very unpredictable and mixed results, and you might end up re-traumatized because that really does happen.

I have worked with three therapists who did know what they were doing. They weren't muddling their way through; they were able to explain to me what they were helping me work toward, what skills they were helping me internalize and why, etc. They had strong confidence that I would reach a place of healing and independence and they were correct. Why would it make any sense for them to have claimed such things as you suggest? It certainly wouldn't have helped me.

I think yes, a client for whom multiple therapies have failed would count as a "challenging case". "Therapy failure" being defined from the client's perspective primarily but I think in many cases both therapist and client might agree.

The generalist-specialist approach to trauma might also have helped in what I think I remember from what you said about your situation, where early in your therapy therapists ASSUMED that your symptoms were the result of trauma without much screening. The therapy for trauma was hurtful to you as well as being ineffective, am I correct? And ultimately it was found that you had another condition, not trauma related.

Focusing on goals could be a good approach for a "generalist" therapist to take, until they, or the client, had reason to think something else might be going on, at which point either the therapist could suggest, or the client ask for, a more complex assessment. The point being that both would know a complex assessment was available.

And for anybody whose generalist therapist has helped them with trauma-related issues, that's great! A lot of people get antidepressants from their GP's for a short time and when that works, great, too! If it doesn't then maybe it's time to see a psychiatrist and/or therapist. I don't see why that couldn't apply to generalist therapists, too.

The main problem for me all these years is that I have been all on my own trying to manage my (complex) mental health situation with a mind challenged by a complex mental health situation!! It's not worked out very well for me, and perhaps put like that, it's easy to see why!

Considering that the most powerful tool every therapist has in their work are themselves then the best training they can get is to have enough therapy themselves before starting to see other people. This also gives the first had experience with transference-countertransference.

This is the model practiced in psychoanalysis - the personal analysis is by far the most important part of the training. Sure, the training also includes theoretical work and case work under supervision, but this can only start after the personal analysis is already long under way.

I think this is fair comment, the best therapists I've seen have had their own long term therapy, which does give a strong sense of what it's like to be a client, the challenges etc as well as them knowing what's theirs and what isn't.

Dont be silly! you should be congratulated, not punished, for going to school!

Certainly no need for you to refrain from posting that I know of! And certainly not based on how your post affected me.

I responded/reacted to your post based on how it seemed to me. It felt to me that my post was pushing on the “boundaries” a little so I put a trigger icon on it. But pushing on (possible) boundaries a little in a relatively “safe” space is something I am "allowing" myself to try, and to try to learn from. So I went ahead and posted, even though it seemed a little over the top, rather than just squelching my response.

Thanks to everybody who has participated in this thread! Despite a variety of different points of view there seems once again to be an unbridgeable gap between two main themes:

(1) The mental health system is basically fine just the way it is. Anyone for whom it hasn’t worked, that just too bad.

(2) The mental health system has hurt or failed to help a significant number of people. They have no ongoing efforts to acknowledge a problem, study the problem, get feedback from clients who feel there has been a problem, etc.

This thread was my (again lame) attempt to think productively about what I feel and believe, based on my long experience with therapy, are some issues. And some suggestions which perhaps the profession could take to help people with mental health issues who have not been helped and have sometimes been hurt by certain therapists or types of therapy.

On a personal level, maybe there comes a time when it’s just time for me to say I have treatment resistant depression and to stop looking for any more help in the mental health profession. But, if so, it would help for someone in the profession to offer that opinion, too. Then, at least we could agree that I have a condition that current mental health therapy does not have any way to help with and that would be that.

For the record, I don't believe your #1 point, personally. The system is far from perfect, or maybe even good. Still, I believe there are many good, effective therapists out there. I think it's extremely difficult to figure out a better system only because of the many variables involved. I do think there are some "givens" that all therapists that should be trained in which include things like never shame a client, never abruptly terminate a client due to transference, etc. And perhaps every therapist themselves should be required to annually take their own mental health examination.

A large part of point #1 makes point #2 very true. The system fails the people that have been wronged in therapy. There is so little protection for clients against unethical therapists because of the power differentiation. To file a report against a therapist is about as easy as raising the dead. Until that changes, bad therapists will continue to rule the roost.

Completely disagree with this being a lame thread!! Far from it! No matter how small, or how "lame" you think your thread may be, you are looking for solutions to help make a difference. You are advocating for change through awareness. Whether people agree with you or not, you are putting your thoughts and ideas out there tactfully, so thank you!

I know it sucks to be treatment resistant. Please keep fighting the good fight -- whatever that may entail for you!