Suggestions for Mental Health Professionals dealing Challenging Cases

I'm not sure anybody else is much interested in this, but if you are I am wondering if you have some thoughts or additional suggestions? Where this may go I am also not sure, nor how to define "challenging cases", but nevertheless . . .

Number (1) is an adaptation of a suggestion Skies made on another thread. (2) is mine.

1. There should be “generalists and specialists. The generalists would get paid less and handle clients with easier issues, while the specialists would have additional certifications/requirements and training” and probably get paid more.

There might also be a case manager for people with challenging difficulties whereas clients with an easier issue, or one which at first seems that way, could deal with a generalist therapist directly.

2. Challenging cases may typically involve some difficult but well-known transferences, such as erotic and negative ones. Any (specialist) therapist dealing with a challenging case needs to have special training on how to deal with these effectively. Additionally, this training in the short term may need to be developed, based on what is currently known, and the training periodically updated and evaluated as better data are gathered and more is known.

Mishandling of these difficult transferences can cause clients a lot of harm. This needs to be recognized by the profession and the specialists dealing with these cases.

But how do you know before-hand if you'll develop difficult but well-known transferences? If these develop with your generalist T, should you be terminated and sent instead to a specialist T?

For me, having the "generalist" stick around and continue to see me while I also see a specialist has been very helpful. I don't know if I would have survived termination with the generalist. I don't really do therapy with the generalist-he mostly provides support, sometimes a place to process, and consistency.

I don't think I would want a case manager. Seems like that just adds a layer of other people thinking they know what is best for me. Also, another person that I have to trust. And another person who I would have to tell my story to. Not to mention that I do not like people talking about my situation and making decisions without me present. I would not (and do not) allow that.

One of my trainers thought that negative transference is required for any depth therapy. I tend to agree, because basically having both positive and negative transference during the course of long-term psychotherapy and working through both helps integrate both positive and negative perceptions of the world and oneself, which leads to a balanced outlook. This is my experience at least.

I think erotic transference has varying degrees of intensity and difficulty. I liked how another trainer put it - that erotic doesn't necessarily mean sexual, that it's about something that makes one come alive. With that definition a lot more becomes erotic than what we tend to think of as such in day to day life.

My point is, I honestly think that giving the "difficult transference" cases to "specialists" would leave no cases for "generalists". Then again, I think this is already sorted out by therapeutic orientation - some schools of therapy deal with transference, others don't take it into account.

Interesting idea otherwise. I think this is done because many therapists end up specializing in certain issues, through training and experience, but to a lesser degree than MDs.

As far as I know there are specialists out there already. I think where things get sticky is so often a client seeks out a therapist not having any idea that they have "xyz" issues and even need a specialist. Especially where attachment insecurities and trauma are concerned (for those with repressed memories). Once that attachment piece is discovered, it's usually far too late to refer the client out with causing damage. And uncovering trauma can take time to reveal itself. Attached or not, some wouldn't want to leave their current t for a specialist after having invested a lot of time and building trust.

Also, there are instances where generalists can handle the client that maybe should have seen a specialist. I think there are too many unknown variables with each client and each t going into the process to make the generalist - specialist idea workable. IMO.

I do think that every t on the planet should have to go through special training to learn how to deal with transference and counter transference effectively. Transference just seems so common.

Thanks so much, and very good points.

I think this would have helped me too..

I too don't care for others (professionals) (irl) conversing about what they perceive as "best for me" (or the "system")

Have you, or would you consider, consulting a "specialist" if your generalist T recommended it and continued therapy with you while you were working with the other T, too?

I think on the other side of things, it is important for "specialists" to have "general" patients. T's are human too, and need to self care like everyone else. If a T is loaded down with too many "difficult cases" they may get burnt out too quickly and not be able to help anyone. I read it somewhere that as a general rule a T shouldn't take more than 3 BPD cases at one time, it becomes too much, and then counter transference issues pop up degrading the therapy of the clients. I can imagine the same rule may apply with other diagnoses.

I agree wholeheartedly with the statement that more T's should be trained in transference and counter transference. A big part of that learning and understanding is a T having their own therapy, to learn and deal with their own transference. It is to the detriment of clients that not more T's do this.

Transference is normal. But it needs to be resolved.

Mostly, I think therapists should be required to have special credentials to take on trauma or otherwise complex clients.

Any therapists could just take 1 course and claim to specialize in trauma. What would that be like of your GI doctor, surgeon, or rheumatologist only took 1 focused seminar course outside of medical school and called themself a specialist?

However, I think their own depth therapy where they work through their own transference is a good bit of their training, too.

Some therapists do 3 session evaluations to assess a potential client. I have only had 1 therapist of many do this over the years. You can almost know someone's diagnosis just from assessing their defense mechanisms and they way they talk-words, affect, patterns, etc.

Psychoanalysts have a way of doing this. I'm not sure if other therapists do. It boggles my mind that they don't do this. I think perhaps they just want clients regardless and know they can simply end the therapy if they later discover the client has more issues that what was on the surface.

I think some of these suggestions are good particularly around training for things like working with trauma. Not every modality works with the concept of transference - feelings are feelings and get addressed and resolved in the room in the relationships between client and T so not every specialist T needs to know how to work with transference specifically. I would add that Ts stay in supervision through their whole career as a matter of course.

But how does a therapist (or even a client) know they are a challenging case? I certainly had no idea early on the complexity of my issues; neither did my therapists. And the degree of complexity was often in flux. What constitutes "challenging"? I didn't have transference issues or attachment issues, but the severity and complexity of my mental illness warranted 15 hospitalizations in around 10 years. My "generalist" therapists did an excellent job and the fact that I have been able to move on from therapy quite healthily despite how seriously ill I had been is good evidence of that.

I warned my t at the beginning, that he was going to need supervision, not because i was worried he was lacking or incompetent in any way, but because i was going to be such a difficult case. Up to him to take my advice or not.

Its called an assessment that i explained above
The assesent that hardly any of them do

An initial assessment, even several months long, won't necessarily predict how challenging a case can become (wouldn't have in my case for sure).

Same here. I didn't know the depths of my issues at initial assessment. Took many, many months for things to start unfolding. And actually, it took a year and a half before a major discovery was made.

It sounds like the level of complexity in your case was handled quite well by the "specialist" treatment of hospitalization when you needed it.

Transference and attachment issues, dissociation, most personality disorders -- I'd say many or most clients with those may need specialists, certainly worth considering and informing the client about.

I think it's fair to say that the success rate in treating clients with those issues is not high, although I can't find any statistics on the internet. That's based on my own personal experience plus experience in a support group of older people who have been in and out of therapy most of their adult lives. None of us have what would be called "severe and persistent" mental illness and are not on disability, but our lives have been limited nevertheless.

I know what youre saying, but a certain type of assessmet does inform about personality and attachment, which is what complexity largely is.

Theres a formal interviewing technique informed by psychoanalysis that gives a therapist a really good idea of the clients issues. This is a highly skilled technique that therapists dont use.

What im saying is these thpes of assessments arent used. They are nothing like your average clinic intake.

And there are easy things-clients who show dissociation right off the bat will likely be complex. The interviewing technique brings that out, as well as determining ego strength.

Nancy mcWilliams has authored a really good book about how to do this.

Other things are obvious-instability in employment, relationships, eating disorders, suicide attemptd childhood trama, recklessness, substance abuse, etc. all point to potentially complex clients.

Another important theme is how someone with unresolved trauma interviews. Theres certain themes throughout that point to heavy use of defenses. These defenses break down in therapy, and hence you have your unpredictable scenario of the client being found to be complex as treatment ensues. Defense mechanisms strongly point to diagnosis and case complexity

Of couse no one can predict 100%, but none of them make an effort by using multiple session intakes.

Sorry for typos.

Adding-i have been thru one. It was nothing like the dozen others, the average clinic intake. It does reveal your issues, to someoe trained to see them. Nancy McWilliams writes an e tire book on how to do this.

Is this an issue that NAMI or some organization like that could address?

And for instance, when someone goes into a psychiatric hospital, even an outpatient program -- why aren't the assessments done there? Too expensive, I guess, insurance doesn't pay for it. Nevertheless. . .

Im not sure.

I think they arent used because its based on psychoanalytic concepts as many schools shun that field.
Which is odd because they have the best training to handle the most complex clients and a history of being tbe first to help those deemed untreatable.

Columbia University and many other reputable institutions make advancements that those outside the dynamic school of thought often are uninformed about

Actually, hospitals do very little generally in terms of therapy. All the hospital did in my case was deal short-term with crisis. They weren't specializing in therapy AT ALL. All of the real work of dealing with the deeper issues involved in my case were handled by my therapist over a much greater period of time and much greater intensity of actual work than was ever involved in my hospitalizations. Hospitalizations generally are short-term crisis management, med management, etc. Therapy and actually work is outpatient work, in my case, done by therapists who I would consider generalists rather than specialists, but they were highly skilled, competent, and effective professionals, quite capable of handling my case when it did become extremely challenging.

My experience with medical specialists is that they have a tendency to be pretty egotistical, often don't work with patients/clients but rather dictate to them because after all they are the experts. The real day-to-day care and maintenance even of complex medical cases often is handled by the general practitioner who coordinates care between the specialists, takes the time to really get to know the patient/client, and quite honestly takes the time to often do the research and work that ends up being of the best help.

I would suspect mental health "specialists" might be prone to those very same personality/professional flaws. In fact, I see it here at times with posters who have had issues with therapists who claim to be experts in a particular therapy modality or issue -- therapists who are inflexible, unyielding, claim to be "the answer", and berate them if they are questioned.

Personally, I've found my eclectic therapists with the ability AND willingness to use a variety of modalities, to choose the right approach at the right time, rather than "specializing" in one issue or one approach, to be highly effective. Not to mention, not ALL of my issues were related to one "specialty" and my issues changed over time, so would a person have to shuffle from specialist to specialist for different mental health issues if they happen to all be challenging? Where is the mental health specialist who handles the complex combinations that often are the reason those cases are complex in the first place? I mean, that specialist would have had to specialize in comorbid bipolar disorder, PTSD, sexual abuse, torture just to name the top four complicating factors in my case. I just happened upon general therapists who had experience in those issues (not necessarily all in one client at the same time) and were skilled enough to put their education and research and experience together to help me.

Look, I'm not saying the idea isn't worth consideration, but the practicality of it and the reality of the multitude of variables making it extremely difficult to put into concrete action, not to mention the wear and tear on a therapist who would be dealing exclusively with only difficult cases just doesn't seem feasible in reality.

I know you are focused on personality disorders and transference, but how many people entered into therapy knowing those were their diagnosis, knowing they would fall into transference issues? How many would have really been identifiable and predictable as complex because of those issues in a few assessment sessions? Often those issues don't arise for months or even years, and sending those clients off to a specialist once those issues do come up, would get marked as abandonment and/or wrongful termination.

Seems that certainly therapists need lots of training in those issues about how to work with them, but the fact is that no two cases look alike, and what works with one client blows up in disaster with another. It IS a great deal of trial and error unfortunately, but it isn't science, it's relationship and communication and on the spot subjective analysis -- all of which can't really be predicted and planned for.

Yes they can. If you call a psychoamalytic imstitute, they normally do this specialized assessment over a few sessions, then offer you treatment if they feel they are a good match, or they refer you to the appropriate specialist. They even say up fron they will refer you to someone who is a good match.

But anyone would have to read the entire book i mentioned to understand how it works and why it is effective.

I would bet you $1000 bucks you can get a grasp on a persons personality disorder in 1 to 3 sessions with tbe training they have.

Its not really relevant if the client knows as many wont, i agree.

Those issues don't arise for months or even years under current methods. It's great that the system-as-usual worked for you. It hasn't for me and others whom I know. Don't we count, too?

I think there's a great danger of trying to put people into distinct boxes and then to treat them for the box they fit into. The issue being that mental illness is an inexact science, assessment tools are far from infallible and in some cases what's helpful to one condition might be actively unhelpful for another.

In the U.K. counsellors and therapists aren't diagnosticians, if you need a diagnosis you go to your GP who might refer to a psychiatrist . This has been helpful for me because my T has never treated me as a condition to be cured, she's treated all parts of me that struggle drawing on a range of knowledge and approaches but mostly she's offered a real, safe, trusting relationship and I've healed more than I thought was possible. Going by the criteria here I would have been considered a "complex case" on a number of levels and my T has a lot of experience working with trauma, but wouldn't meet the standard of specialist training talked about here.

Given in some places accessing any form of therapy is a nightmare, I think the issue of competence is more than training or governance- it's about the intention and integrity of the therapist to know their own limits and work within them, or to seek early specialist supervision if they're working in an area that's new to them.