Welcome to the Spring 2017 edition of the dilemmas page, in which we ask for answers to fictional ‘what if’ nightmare scenarios that we might find ourselves in as psychotherapy trainees. The range of responses from our readers from within the psychotherapy world provides us with tools should anything similar ever happen to us in our personal practice.
A client who you have been working with for a few months came to you originally saying that after a suicide attempt in their teens, they had been diagnosed with schizotypal personality disorder by a psychiatrist and have been on medication for two years. After a month of working with you they express the feeling that they disagree with their diagnosis, and would like to end their medication as well as contact with their psychiatrist immediately. They express many unconventional spiritual beliefs and believe in magic etc but have not made any inclination of being suicidal in the time you have worked with them. How would you approach this situation?
Suzie Chick’s response
“A lot of points come to my mind on this situation, these include:
There’s a lot to explore with the client on their recent disclosure. For example, I’d want to enquire why the client has had this change of heart about their diagnosis and medication? I’d also want to explore what the diagnosis means to them and likewise with their medication.
My sense is maybe the client is starting to gain a sense of autonomy over their mental health and understandably wants to question things, especially around decisions, which may have been made when they were a teenager.
My position to the client would be that it’s always good to review their treatment but in regards to medication especially it would need to be done under supervision of their psychiatrist.
I would make clear that I was not a psychiatrist and that I could not advise them on their medication or change/remove their diagnosis. I would want to explain that to do that would be working outside of my area of knowledge and therefore would be unethical.
I would recommend that they arrange a consultation with their psychiatrist to talk this through. If they refuse then I would reiterate my concerns especially about them self- medicating. I would ask their permission to make contact with their psychiatrist instead. Hopefully upon contracting, the limits of confidentiality had been made clear so the client would appreciate that this is about ensuring their best interests.
In terms of their unconventional beliefs, I would work with their reality and what they bring to session and not try to rationalize or dissemble their beliefs. Also unconventional beliefs are sometimes a symptom of their diagnosis, so I wouldn’t be too concerned especially as they are not showing signs of feeling suicidal.
As always, I would talk all of this through with my supervisor and keep checking back with them as the sessions unfold.”
This dilemma brings up a lot for me around the issue of power relations in therapy. About how much agency is given by the mental health system to people who are coming for treatment, and how this can sometimes be undermined whilst being justified as ‘best practice’. I have a client who is disagreeing with their diagnosis and wants to end contact with their psychiatrist. My first point of exploration would be to ask – what it is that psychiatry and their diagnosis means to them? What type of medication are they on? What function do they feel it serves for them?
This would help me to get some idea of what purpose the medication has and what it may be doing for the client, if a mild, low dose antidepressant (for example) I would be far less concerned than if they were immediately stopping a strong antipsychotic medication. It would also allow the client to explore in detail the effect that their medicine has on them and allow them to double-check that they feel that it is a good idea to stop, as well as clarifying what associations they have with the mental health system. What is the lived experience of being seen as ‘mentally ill’, what about their diagnosis and medication are they attempting to escape from? Do they want to feel ‘normal’? I would also look at the way that their unorthodox beliefs may be seen as a symptom of illness and how the client feels about this – what does it feel like to have your worldview labelled ‘disordered’? Especially your spiritual beliefs?
In terms of relationships, I would be interested in why they are choosing to abandon their psychiatrist and yet remain working with me around the issue of their mental health, especially after such a short time in therapy. Perhaps there is some ‘splitting’ going on with the psychiatrist and the medical side of the health system representing something negative which needs to be escaped from. Perhaps psychotherapy is being seen as an ‘escape route’.
This information – about the client’s lived experience – would be needed to know how to proceed in regards to contracting around how they want to proceed with the withdrawal and psychotherapy in the future.
Next Issue’s Dilemma – Mother and Daughter
You have been working with a client who has brought the presenting issue of being bullied at work by their two female bosses. At 6 sessions into the therapy the client arrives with their mother in tow and asks for you to see them both for the session, without giving you any prior notice – her mother seems insistent that you let her join in with the session. There has not been much discussion of the relationship between your client and her mother in therapy so far, which has focused more on the issue of the relationships at work. You know that in general the client has not complained too much about her mothers behaviour, but you do not have a clear image of how their relationship has been in the past. As therapist how do you deal with this situation?